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1. REQUEST RELEASE DATE -'� <br />REQUESTING AGENCY ! o <br />As PHONE NO. -- 9 !c <br />3. AGENCY ADORES S K r -- <br />m <br />4. INDIVIDUAL REQUESTING, c - T- „� SF,a r- PHONE NO. <br />5. INDIVIDUAL ADDRESS Sp <br />FILE ADDRESS ITEM -REQUESTED DATE PURPOSE OF REQUEST <br />o4 x,• --- <br />*ASTERISK <br />•t <br />*ASTERSK ITEMS REQUESTED POR PHOTOCOPYING <br />SIGNATURE OF REQUESTING PARTY,�.�,,,/ �� --- <br />C GATE � � � /a � <br />LOCAL HEALTH DISTRICT USE ONLY <br />PROJECTED RELEASE DATE <br />SIGNATURE OF RELEASING OFFICIAL <br />DATE <br />NAMES OF STAFF MEMBERS INVOLVED IN THE RELEASE AND. MONITORING OF THE RECORDS. <br />cRr <br />nn -.IA . <br />. .... ..� ,.� ... �:... ., e,.;,x�,,,,�_,vc.. .p.o a .i!'•°.%�'�:•.�...— <br />,A /Q1 <br />